Psychiatry
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COUNSELING SESSION

Last Counseling Session:[date name="variable_1" default="03/28/2019"]
Last Medical Appointment:[date name="variable_2" default="03/28/2019"].
Last drug screen:[date name="variable_3" default="03/28/2019"] and results reported as [select name="variable_4" value="normal|abnormal"].

D: Client came to office to meet with this writer [checkbox name="reason" value="to engage for monthly counseling|at the request to see counselor"].

Writer invited client to initiate session by asking client to share their current status. Client reported to [textarea name="variable_5" default=""].

Writer demonstrated active listening skills, and when client finished reporting self-identified status, this writer used reflection, and clarified client's priorities and readiness. Using a collaborative approach to agenda map with client identifying [text name="variable_6" default=""] as being an area which could be a primary focus for this session.

Writer used open-ended questions to assist client in exploring the problem further, and this writer assessed client's understanding and previous barriers. Writer provided affirmations and built confidence through ask-tell-ask, where praise was given to support [comment memo="Praise: specify at least 1 positive event, attitude or strength of client identified"][text name="praise" default=""].

Client was asked to consider incremental changes to address their reported barriers. Client was able to identify [text name="variable_7" default=""] as a possibility. Writer used scaling questions to assess readiness and commitment and worked collaboratively with client to develop a plan that includes adequate structure, accountability, benchmarks and rewards. Client and this writer developed homework for next session.

A: Client appears to be in [select name="variable_8" value="pre-contemplative|preparatory|action|maintenance"] stage of change as evidenced by [textarea name="variable_9" default=""]. Client's progress in achieving treatment goals is best assessed as "[checkbox name="progress" value="minimal|inconsistent|progressing|improving|stable"]" as evidenced by client's self-reports, drug screen results, behavior and engagement.

P: Next session scheduled for [date name="variable_10" default="03/28/2019"]. Client reports commitment to [text name="v" default=""] prior to next session. This writer will remain available to offer ongoing resources if client needs support between session.

RESOURCES PROVIDED:
[checkbox name="RE" value="MI worksheet- Agenda Mapping.|MI worksheet- Exploring Pros and Cons|MI Worksheet- Change Plan|List of Community Resources for |Referral to |Phone Numbers for "][comment memo="Use text box to add specific resources, resources not listed, or indicate none"][textarea name="variable_1" default=""].
COUNSELING SESSION

Last Counseling Session:
Last Medical Appointment:.
Last drug screen: and results reported as .

D: Client came to office to meet with this writer .

Writer invited client to initiate session by asking client to share their current status. Client reported to .

Writer demonstrated active listening skills, and when client finished reporting self-identified status, this writer used reflection, and clarified client's priorities and readiness. Using a collaborative approach to agenda map with client identifying as being an area which could be a primary focus for this session.

Writer used open-ended questions to assist client in exploring the problem further, and this writer assessed client's understanding and previous barriers. Writer provided affirmations and built confidence through ask-tell-ask, where praise was given to support Praise: specify at least 1 positive event, attitude or strength of client identified.

Client was asked to consider incremental changes to address their reported barriers. Client was able to identify as a possibility. Writer used scaling questions to assess readiness and commitment and worked collaboratively with client to develop a plan that includes adequate structure, accountability, benchmarks and rewards. Client and this writer developed homework for next session.

A: Client appears to be in stage of change as evidenced by . Client's progress in achieving treatment goals is best assessed as " " as evidenced by client's self-reports, drug screen results, behavior and engagement.

P: Next session scheduled for . Client reports commitment to prior to next session. This writer will remain available to offer ongoing resources if client needs support between session.

RESOURCES PROVIDED:
Use text box to add specific resources, resources not listed, or indicate none.

Result - Copy and paste this output: